Shipping Occurrences

Report
DUTCH
SAFETY BOARD
page 2

Investigations
Within the shipping industry, the
Dutch Safety Board has the legal
obligation to investigate serious
and very serious occurrences
involving Dutch seagoing
vessels. This obligation also
extends to the investigation of
serious and very serious occur- May - October 2020
rences involving or on board
seagoing vessels in Dutch terri-
torial waters. The Dutch Safety In June 2015, the Dutch Safety Board published the first Shipping
Board carries out these investi- Occurrences Report. With the tenth edition you were given the opportunity
gations in accordance with the to indicate what you think of the Shipping Occurrences Report. In this new
Kingdom Act concerning the edition you can see what the survey has yielded.
Dutch Safety Board and the EU
Directive 2009/18/EC of the In the foreword of the first edition, the shipping branch was described as
European Parliament and the the silent motor of our economy, operating in the shadow of the public page 7
European Union Council of 23 attention. This is the eleventh edition of the Shipping Occurrences Report.
April 2009, establishing the The shipping branch is still the silent motor of our economy, which, even in
fundamental principles gover-
times of COVID-19, and despite the many limitations for crew members, is
ning the investigation and
still running at full power.
prevention of maritime acci-
dents. When the Dutch Safety
How the shipping branch contributes to the economy became clear when
Board decides that no structural
a variety of consumables from containers lost by the MSC ZOE washed up
safety shortcomings are involved
on the beaches of the Dutch Wadden Islands in January 2019. The opening
with regard to a serious incident,
article therefore focuses on minimizing the risks of loss of containers.
a description of the occurrence is
sufficient. The main goal of the
Dutch Safety Board is to prevent Not only the risks of losing containers must be minimized. The accidents
accidents or their consequences described and the statistics in this edition show that the number of
by determining lessons learned occupational accidents is high. Greater insight into the nature of these
and formulating recommendati- accidents can assist in increased safety awareness among employers,
ons. Investigating who is to employees and other parties in the maritime sector.
blame or liable is expressly not a
part of the investigation by the Jeroen Dijsselbloem, chairman of the Dutch Safety Board
Dutch Safety Board. page 29
 Minimizing the loss
of containers
requires an
integrated approach
On the night of 1 to 2 January 2019, the Panamanian
flagged containership MSC ZOE (19224 TUE) lost 342
containers to the north of the Wadden Islands. This was
not the first occasion that a ship had lost containers on
that route, but the numbers made a deep impression.
Never before had a ship lost so many containers at
one time, on this route. The beaches of the Dutch and
German Wadden Islands and the coast of Friesland and
Groningen were awash with the contents of the containers.
For months after the occurrence, the cargo of the MSC
ZOE continued to wash ashore. The possible long-term
damage to organisms can still not be fully assessed, but
the pollution itself represents considerable harm to the
natural value. Where in the past the losses of containers
had been dealt with basically as a matter for insurers, the
loss of the containers by the MSC ZOE was classified as a
‘very serious’ marine casualty based on its environmental
impact.
2 - Dutch Safety Board
Top view MSC ZOE after losing 342 containers.
The number of containers lost by the MSC ZOE has sadly
already been overtaken by even larger numbers lost. On
30 November 2020, the ONE Apus (14052 TEU) lost 1816
containers and on 16 January 2021, the Maersk Essen
(13100 TEU) lost around 750 containers. The impact of
these losses has to date only become clear on board. In
both cases, not a single container has been retrieved; the
containers and their contents still remain in the Pacific
Ocean.
These recent occurrences have focused greater attention
on determining how containers are lost overboard. It has
for some time been known that weather conditions play
an important role. Weather routing1 has become a widely
used term among operators of large container ships.
Based on weather forecasts and other factors, the best
potential route is calculated. For large container ships,
avoiding bad weather areas is a key factor. Changing
course to avoid bad weather is relatively easy on the open
ocean, but on other routes, for example on the North Sea,
such options are not available.
1 Weather routing is a commercial service provided by commercial
companies to cargo vessels, to optimise their journey performance.
Whereas small container ships with limited stability
only lose small numbers of containers, the recent losses
of containers show that large, wide and stable (high
GM2) container ships are apt to lose large numbers of
containers. It is slowly becoming clear that large, wide and
stable container ships represent new risks with regard to
the loss of containers.
The loss of containers by the MSC ZOE north of the
Wadden Islands lead to two investigation reports.
First there is the report from the international joint
investigation into the cause of the loss of containers by
the MSC ZOE, the ‘Joint Investigation Report MSC ZOE3 4’
(see the summary later in this report). This report was
written in cooperation between the Flag state Panama
and Coastal States Germany and the Netherlands.
Second there is the report of the Dutch Safety Board ‘Safe
container transport north of the Wadden Islands 5’ (see the
summary later in this report). This report arose in response
to the question of what the Netherlands can do to prevent
such accidents and, if they do occur, to limit their harmful
consequences as much as possible. To harmonize the
(interim) results and to determine follow-up steps of the
two parallel investigations, joint meetings were organized.
In addition, authoritative maritime experts of the Technical
University of Hamburg, Deltares and MARIN have
contributed to the investigations.
The investigations that lead to the reports mentioned
above have for example revealed that for large, wide and
stable container ships, there are route-specific risks on
the shipping routes north of the Wadden Islands. Four
hydrodynamic phenomena were measured and observed,
which can individually and in combination introduce a risk
of loss of containers. The four hydrodynamic phenomena
are: extreme ship motions resulting in large accelerations
and forces on lashing equipment and containers, contact
with the seabed, green water and impulsive wave impacts
(slamming) against the ship.
2 Metacentre height, an indicator of the stability of a ship
3 https://www.bsu-bund.de/EN/Publications/Unfallberichte/_functions/
unfallberichte_table_2020.html?nn=1351146
4 https://www.onderzoeksraad.nl/nl/page/13223/veilig-containertransport-
ten-noorden-van-de-waddeneilanden.-lessen
5 https://www.onderzoeksraad.nl/nl/page/13223/veilig-containertransport-
ten-noorden-van-de-waddeneilanden.-lessen

Observation of green water during de basin tests by MARIN.
It has of course been known for many years that based on
its water depth, the North Sea imposes restrictions on the
draft of passing ships. The draft restrictions in combination
with the direction of the traffic flow (full containers towards
Europe) with imports from Asia and empty containers
on the return journey) in practice means that the centre
of gravity of the ship on this part of the route is relatively
low, making the GM high. The higher the GM, the greater
the stability. The greater the stability, the shorter the
ship’s own oscillation period. Research has shown that the
development of these large, wide and stable container
ships has meant that under specific circumstances, the
vessel’s own oscillation period can come close to the peak
period of the waves on the North Sea. As a consequence,
under these specific circumstances, these large, wide and
stable container ships can easily start to roll.
The short oscillation period of the vessel means that
once the ship starts to roll, it leads to high accelerations
and forces on the containers, the lashing equipment
and the deck of the container. The basic equipment and
technology and the way they are employed in terms of
securing containers have remained the same, irrespective
of the ship’s size. The investigation into the loss of
containers by the MSC ZOE has shown that the forces and
accelerations that occur closely approach the design limits
of the lashing equipment.
Because the acting forces and accelerations on lashing
equipment closely approach the design limits, the risk of
losing containers will become even larger if the containers
are not properly lashed. The subject lashing was recently
the focus of a report by the Human Environment and
Transport Inspectorate (ILT) 6 ‘The lashing of containers
on seagoing vessels’. The ILT investigated compliance
with the regulations for the securing (lashing) and storage
of containers on seagoing vessels. In 67% of the ships
investigated, violations were observed in relation to
the loading and securing of containers and the lashing
equipment employed. Violations ranged from failure
to have a complete Cargo Securing Manual (CSM)
and failing to secure the cargo according to the CSM
regulations through to exceeding the deck load. These
are serious shortcomings in the way the work is done
and they lead to a higher risk of losing containers. The
investigation into the loss of containers by the MSC ZOE
demonstrated that even without these shortcomings,
the risk of losing containers in periods with heavy rolling
is large, because the design limits of lashing equipment
are exceeded. In the report ‘Joint Investigation Report
MSC ZOE’, recommendations were made relating to the
design requirements on lashing systems and containers,
and obtaining a greater understanding of the oscillating
movements and accelerations that occur on container
ships.
Damaged lashing equipment after the loss of containers.
Following the recent incidents with large numbers of
lost containers, it could easily be forgotten that relatively
smaller ships also continue to lose containers. The OOCL
RAUMA (1425 REU) lost seven containers in February
2020, 32 nm North of the Wadden Islands. And the
English Marine Accident Investigation Branch for example
6 https://www.ilent.nl/onderwerpen/lading-op-zeeschepen/documenten/
publicaties/2020/05/14/sjorren-van-containers-op-zeeschepen
launched an investigation in November 2020 into the loss
of 33 containers in the Pentland Firth (see elsewhere in
this Shipping Occurrences Report). The similarity with the
previously described losses is that the containers were
lost in bad weather and one or more of the previously
described phenomena occurred.
Minimizing the risk of the loss of containers requires
an integrated approach by the parties involved. The
Panamanian, German and Dutch government have
received the recommendation to submit a proposal to the
International Maritime Organization to review the technical
requirements imposed on container ships. The Dutch
Minister of Infrastructure and Waterways has expressed
her commitment to this.
Making changes in a sector demands dedication and
patience. Proposals for changes via the International
Maritime Organization (IMO) are lengthy processes but
that does not mean that other options are not available
in the meantime. The Dutch Ministry of Infrastructure and
Water Management has now taken the first steps towards
a follow-up investigation into the loss of containers by
smaller ships and in other weather conditions. Other
recommendations for the shipping routes above the
Wadden Islands are aimed at introducing traffic control on
the shipping routes and innovation in relation to the active
notification of prevailing weather and wave conditions in
the area.
In addition to these developments, there is a clear role
for the worldwide shipbuilding industry and shipping
operators. Recent occurrences make it clear that the limits
of the systems currently used are quickly approaching.
It is time to critically examine the shelf life of the current
systems in combination with the circumstances that occur
in practice. The Dutch container and shipping industry can
play a role - both as a binding force and a driving force
- by taking the initiative in initiating improvements in the
international world of container transport.
Shipping Occurrences Report - 3
 Accident In this Shipping Occurrences Report, the Dutch Safety
Board registers the description of reported accidents on
board ships sailing under the Dutch flag or accidents that
Serious injury: injury suffered by a person that has meant
that the person has been incapacitated for work for more
than 72 hours within seven days after the date on which

classification
have occurred within Dutch territorial waters and reports the accident took place.
published between 1 May 2019 and 1 May 2020.
This report lists occurrences from the following categories:
Each accident is classified according to seriousness. The very serious, serious and serious injury. In addition to data
categories match EU Directive 2009/EC/18: about the reporting period, a multiyear overview is also
included. This provides a greater insight into trends.
Very serious: accident where the ship is a total loss or where
there have been fatal victims or serious environmental
damage.

Serious: accident involving a ship that cannot be classified

as ‘very serious’ and where for example a fire, collision,
grounding, etc. has occurred that has meant that the ship
cannot continue to sail or causes environmental damage.
This category also includes loss of control of the vessel
following a technical failure if the vessel subsequently has
to be assisted into port.

Less serious: accident that cannot be qualified as ‘very

serious’ or ‘serious’.

Marine incident: an event, or series of events, other than

an accident that has taken place and is linked to shipping
operations that put at risk the safety of the ship, a person
on board or the environment or that would have put any of
these at risk if it had not been rectified.

30
2727
25

20

Very Serious
15
1212
Serious 10
6 6
Serious Injury 5
3 3
2 2 2 2 2 2 2 1 1
Totaal 0
Collision Occupational Fire/ Grounding/ Discharge/ Mast break Falling Non-work- Damage Not under Technical Lost cargo Shifting/ Sinking/ Disruptive water
accident Explosion Stranding Spillage overboard related command failure Movement Capsizing/ movement
of cargo Taking on water

Figure 1: Serious and very serious accidents, shipping, period May 2020 to November 2020.

4 - Dutch Safety Board

 300

256
250
233

200

Very Serious
150

Serious 100
7979
Serious Injury 52 53
50 33
23 29
1818 20 21 9 1 10
1 1 3 3 4 4 2 2 10 10 1 3 4 1 4 5 1 1
Totaal 0
Collision Occupational Fire/ Grounding/ Discharge/ Mast break Falling Non-work- Damage Not under Technical Lost cargo Shifting/ Sinking/ Disruptive water
accident Explosion Stranding Spillage overboard related command failure Movement Capsizing/ movement
of cargo Taking on water

Figure 2: Serious and very serious accidents, shipping, period January 2016 to November 2020.

100

90

80
86

70 78

60 59
54 52
50
50

40

Very Serious
30 26
22
Serious 20
16 16
Serious Injury 10 8
5 7 7
3 4 3 3 3 4
1 2 2 1
Totaal 0
Entrapment Electrocution Hit by liquid/ Cutting Falling from height Falling/slipping/ Burning Choking/poisoning/ Unknown
object/etc. tripping/collision drowning

Figure 3: Occupational accidents linked to the cause of injury Shipping, period January 2016 to November 2020.

In the Figures 1 and 2, occupational accidents occupy a
key position. The prevention of occupational accidents has
also been awarded a prominent position in (international)
rules. The international Maritime Labour Convention (MLC
2006), which contains these rules, is viewed alongside the
SOLAS Treaty, the Marpol Treaty and the STCW Treaty
as the fourth pillar of maritime regulations applicable on
board seagoing vessels. MLC 2006 was drawn up under It is noticeable that entrapment, impact by liquids, falling
the flag of the International Labour Organization (ILO). (from a height) are the most common types of occupational
Greater insight into the nature of these accidents can accidents.
assist in increased safety awareness among employers,
employees and other parties in the maritime sector.
For that reason, in Figure 3, occupational accidents are
displayed on the basis of causes of injury.

Shipping Occurrences Report - 5

 Survey
The last edition of the Shipping Occurrences Report
(May 2019 - May 2020) included an invitation to complete
a survey. The Dutch Safety Board would like to thank
everyone who completed the questionnaire. The number
of questionnaires is sufficient to form a picture of the
general opinion.
The readers’ survey contained questions about elements
of this Report you consider positive, and possible
suggestions for improvements. Firstly, the Shipping
Occurrences Report is seen as a valuable addition to the
published investigation reports. The results of the survey
show that you above all appreciate the theme section,
while the chapter providing a description of incidents that
have not been extensively investigated seems to offer the
least added value.
In this new edition of the Shipping Occurrences Report,
we have decided in the case of certain incidents to draw
parallels with accidents that were previously investigated.
In this way, previous investigations and recommendations
can be linked to incidents that although not extensively
investigated, do share similarities. In the chapter featuring
incidents that have not been extensively investigated,
between the various incidents, you will therefore find short
texts referring to previously published reports. It will be
examined per edition whether it is possible to make such
a link. In this way, the Safety Board hopes to once again
draw your attention to recommendations from previously
published reports, for accidents that recur more often.

You have become used to the Safety Board writing the

full story in our report, from course of events and analysis
through to conclusions and possibly recommendations.
The chapter with Incidents that have not been
extensively investigated contains nothing more than a
brief description of the course of events, without further
analysis or outcomes. Because these incidents have not
been investigated by us. The reason for the Safety Board
including these incidents in the Shipping Occurrences
Report is that although they have not been further
investigated, these incidents often provide valuable
lessons for the sector.

6 - Dutch Safety Board

Published Reports
Fall from height, fatal accident on board
Fortunagracht, Puerto de Sucre,
Venezuela, 16 February 2018
On 16 February 2018, a deckhand fell from a height of 12
metres into the hold of the Dutch ship de Fortunagracht.
He died later that day in hospital from injuries suffered as a
consequence of the fall. At the time, the ship was anchored
close to the port of Puerto de Sucre in Venezuela.
The deckhand fell because in the dark, he stepped
through a door opening behind which there was no
tweendeck. Shortly before the accident, the configuration
of the deck had been altered, including the relocation of
the tweendeck behind the door. There were no barriers to
prevent someone stepping through the door opening. At
the time of the accident, the deckhand was alone and in an
unlit area, looking for lashing equipment.
The accident was classified as a very serious accident. In
its report, the Safety Board concludes that on ships with
the possibility of adapting the deck configuration, there
must strict supervision to ensure that doors leading to
the hold are fully closed and locked prior to the removal
of the decks (pontoons). In addition, extra barriers must
be present to prevent a person stepping through a door
that leads to the hold. In its report, the Safety Board also
issued recommendations about the safety culture and
emergency medical treatment.
The report was published on the website of the Dutch
Safety Board: https://www.onderzoeksraad.nl/en/
page/17166/fall-from-height---fatal-accident-on-
board-fortunagracht.
Shipping Occurrences Report - 7

Published Reports
Loss of 342 containers, MSC ZOE, north
of the Wadden Islands, 1-2 January 2019
On the night of 1 to 2 January 2019, the MSC ZOE lost
342 containers to the north of the Wadden Islands. In a
storm-force northwesterly wind, the container ship was
sailing toward the German port of Bremerhaven in the
Terschelling-German Bight traffic separation scheme (the
southern shipping route). The course of events of this
very serious shipping accident was investigated by an
international investigation team comprising the Panama
Maritime Authority (PMA), the German Bundesstelle für
Seeunfalluntersuchung (BSU) and the Dutch Safety Board.
The report of this investigation considers the causes of
the occurrence and the potential lessons learned. The
occurrence led the Dutch Safety Board to also launch an
additional investigation into the route-specific risks on the
shipping routes north of the Wadden Islands, which could
result in the loss of containers on ships like the MSC ZOE.
The insights of the route-specific risks have been included
in the facts report.
Both reports are available on the website of the Dutch
Safety Board: https://www.onderzoeksraad.nl/en/page/
13223/veilig-container transpor t-ten-noorden-van-de-
waddeneilanden.-lessen.
8 - Dutch Safety Board
Safe container transport north of the
Wadden Islands - Lessons learned following
the loss of containers from MSC ZOE
The Safety Board called upon the knowledge and research
institutes Deltares and MARIN to contribute to the
investigation by the Dutch Safety Board, based on their
own expertise, to gain a greater insight into the extent to
which the environmental conditions on the shipping routes
north of the Wadden Islands contribute to the risk of loss
of containers by large ships. These highly stable vessels
are in principle more difficult to remove from their steady
state, but as a consequence also return to that steady state
more quickly. The joint investigation provides new insights
into the circumstances, ship movements and phenomena
that occur in the area investigated.
The investigation revealed that specific risks occur on both
shipping routes north of the Wadden Islands. These risks
are the consequence of high waves approaching abeam,
the limited depth of the shipping route and the high
stability of large, wide container ships. In basin tests, four
hydrodynamic phenomena were measured and observed
which individually and in combination can result in the loss
of containers. It is concluded that both on the southern
and northern shipping route, large, wide container ships
like the MSC ZOE, in a stormy northwesterly wind, run the
risk of failure of the lashing systems and containers, and as
a result of that may lose containers. On both routes, the
loss of containers will result in pollution of the North Sea
and, depending on the wind and current direction, of the
vulnerable Wadden area.
There are no specific guidelines, restrictions or
requirements for container ships when using the northern
or southern shipping routes above the Wadden Islands.
Managing the risk of loss of containers in poor weather
conditions, in the current situation, depends on the
actions of the captain and crew. The authority to impose
binding regulations on the use of these shipping routes
or to change the location of the routs lies with the
International Maritime Organization (IMO) and not with
the Netherlands. Improvement measures via the IMO take
years to achieve, and as a consequence will only have an
effect on the risk management of loss of containers near
the Wadden Sea, in the longer term.
Joint Investigation report, Loss of
containers overboard from MSC ZOE,
1-2 January 2019
The main cause of the loss of containers by MSC ZOE
was the high stability at which the ship was sailing in a
beam sea scenario in shallow water conditions where
it encountered combination of the four hydrodynamic
phenomena. The encountered transversal accelerations
were at the design limits, leading to failure of the container
structure and/ or the lashing equipment and subsequent
container loss. There were at least six moments at which
the MSC ZOE lost containers. The first losses of containers
were not noticed by the crew.
The MSC ZOE was sailing in a high stability condition. The
high stability of large and wide Ultra Large Container Ships
leads to shorter natural roll periods than smaller ships with
lower stability. This brings the natural roll period closer to
the wave periods that were present above the Wadden
Islands during the accident, resulting in larger resonant
roll motions in the beam seas. The shorter periods also
result in higher accelerations. Container ships like the MSC
ZOE have insufficient roll damping in situations with large
stability. High stability is a safety risk that has not been
recognized and formalized in the IMO Intact Stability Code
and documents as the Stability Booklet. Current limits are
only set for a minimum GM. The effects of high GM are
underestimated.
The MSC ZOE is an ultra large container ship built in
2014 with a length of almost 400 m, beam of 59 m and a
theoretical capacity of 19,224 TEU. In general, the capacity
of individual container ships doubled over the last 15
years. The size of the container ships continue to increase,
as well as the share of the large ships in the fleet. This
investigation revealed that the concept of the lashing of
containers on deck of these large and wide ships needs
to be reviewed and international technical and operational
standards to be amended or developed where necessary.
The Joint Investigation Report MSC ZOE is also available
on the website of the BSU: https://www.bsu-bund.de/
EN/Publications/Unfallberichte/_functions/unfallberichte_
table_2020.html?nn=1351146.
Fire in engine room, DC Vlaanderen
3000, North Sea, 19 March 2020
On 19 March 2020, the DC Vlaanderen 3000 lost power as
a result of a fire in the engine room. The fire was caused
by a leak in the lubricating oil pipe. After fuel supply to
the engine room was shut off, causing the main engine to
shut down, the crew activated the solid CO2 extinguisher
installation and put out the fire. The ship was able to return
to Breskens using the bow thruster for auxiliary power. The
next day, when the engine room was opened, it became
clear that besides the leak from the lubricating oil pipe,
there was no further damage in the engine room. There
were no injuries as a result of the incident.
The incident was classified as ‘serious’. The cause of the
incident was a crack in a pressurized lubricating oil pipe
close to the turbocharger. As the pipe cracked, lubricating
oil was sprayed onto a hot surface on the main engine,
causing it to ignite.
Despite the limited damage and the lack of victims, the
Federal Bureau for the Investigation of Maritime Accidents
(FOSO) in Belgium issued valuable lessons as a result of
the incident.
The full report is available on the website of the FOD
Mobility: https://mobilit.belgium.be/nl/resource/report_
dc_vlaanderen_3000.
The damaged lubricant oil pipe. (Source: DC Vlaanderen 3000)
Shipping Occurrences Report - 9
 Completed
Fire in engine room, Maas approaches,
26 June 2017
investigations
On 26 June 2017, a fire occurred in the engine room of a
Dutch cargo vessel. The vessel was en route to Rotterdam,
without report
and was already in the approach to the port entrance.
The crew succeeded in extinguishing the fire, and the
ship was towed into Rotterdam. As a result of the fire, two
crew members were injured, and the ship suffered serious
damage. The almost 90 metre-long ship was in compliance
with the requirements in the manning certificate with
a captain, first officer, maritime officer and 2 ratings, on
board. There were a further 3 trainees on board. The
maritime officer had just graduated from school, and was
making this first trip. He had been given responsibility
for the engine room. The fire occurred when lubricating
oil from the main engine escaped from a filter, under
pressure. The lubricating oil formed a mist which filled the
engine room, and ignited when it came into contact with
hot parts of the main engine.
Following the accident, the Safety Board launched an
investigation. A number of interviews were held, and an
investigation was carried out on board. Based on the facts
observed, the course of events was determined:
• The lubricating oil spray occurred after the maritime
officer removed a venting bolt from the filter, while the
filter was still under pressure;
• The safety mechanism intended to prevent this action
and that also issued a warning, was not recognized as
such. The mechanism consisted for a triangular cover
that held three of the four attachment bolts of the filter
cover in place. The cover was attached by the venting
bolt and was fitted with a milled duct along which oil
was able to escape, if the bolt was slackened, while the
filter was still under pressure;
• Before removing the venting bolt, the pressure on the
filter should have been released by redirecting the
lubricating oil to another filter, by means of an operating
handle. However, the operating handle was incorrectly
fitted, so that the indicator on the handle showed
that the oil was being redirected via the other filter;
10 - Dutch Safety Board
• Because the handle was incorrectly fitted, it could
not be operated, so that the lubricating oil would be
directed via the other filter, therefore halting the spray
of escaping oil. The handle was blocked by pipework
on the engine;
• The lubricating oil mist activated the fire alarm. After
the oil mist had been identified as the cause of the fire
alarm, the risk of fire or explosion was not recognized.
Two crew members remained in the engine room to
shut down the main engine manually. The emergency
stop on the bridge could also have been used to shut
to down the engine;
• Both crew members saw the fire start and were barely
able to escape from the engine room, but they did
suffer burns;
• Before the fire could be extinguished with CO2, all
ventilation openings with fire valves first had to be
closed. The fire valve below the outside stairs to the
bridge was difficult to close, because the operating
handle was difficult to reach as a result of smoke and
heat.
Stairs to
bridge deck
Engine room
ventilation shaft
Operating lever
ventilation flap
Position of operating handle fire valve engine room ventilation.
(Source: Dutch Safety Board)
 Grounding following steering problems, Actions taken by the ship manager to prevent recurrence
Hoek van Holland, 8 February 2020 include:

• Revision of the procedures for applicable preventive

Top of filter cover, including safety cover. (Source: Dutch Safety
Board)
An oil tanker sailing under the flag of the Marshall Islands
ran aground on 8 February 2020 on the breakwater
between the Caland Canal and the Nieuwe Waterweg
following steering problems. The maritime authority of
the Marshall Islands, the Republic of the Marshall Islands
Maritime Administrator, carried out an investigation into
the occurrence, and issued the following findings.
The grounding took place when the steering device failed
while the ship was entering the Nieuwe Waterweg, from
the sea. The vessel had two motors for the steering device.
One of the 2 motors was not available because a number
of components had to be replaced. There were insufficient
spare parts on board to solve the problem.
maintenance;
• Evaluation/review of the critical stock of spare parts;
• Consultation with the manufacturer of the steering
device about the failure of the sensor;
• The issuing of a safety bulletin to the fleet containing
the lessons learned from this incident, and a
prohibition on entering port with just 1 motor available
for the steering device; and
• Training for the captain.

The port authorities had given permission to enter the

Nieuwe Waterweg, with just 1 motor available for the
steering device. They did impose the condition that a
tugboat be deployed to offer assistance if necessary,
but this tug was delayed. In consultation with the pilot,
the captain nonetheless decided to enter the Nieuwe
Waterweg.

The causes identified relating to the management of the

ship are as follows:

• The captain underestimated the risks of entering a

port. The captain’s concerns were focused on setting
anchor, in combination with the weather forecast.
He focused insufficiently on taking additional safety
measures in connection with the fact that he had only 1
motor available for the steering device;
• Failure to halt the entry manoeuvre when it became
clear that the tugboat that was due to offer assistance
was delayed;
• A sensor from the hydraulic tank issued an error
message, activating the low level alarm. The solenoid
valve responded to the alarm, causing the rudder to
become stuck, and no longer be responsive.

Inverted safety cover with venting bolt. (Source: Dutch Safety Board)

Shipping Occurrences Report - 11

 Started
investigations

During the period covered by this Shipping

Occurrences Report, the Dutch Safety Board
has started no new shipping investigations.

12 - Dutch Safety Board

Investigation started
by foreign authority
with the Netherlands
as a state with
substantial interest
Crew members of chemical tanker injured
in lock by broken mooring line,
Terneuzen, 1 May 2020
On 1 May 2020, two crew members of a Maltese chemical
tanker were injured while mooring in the Western Lock in
Terneuzen when the forward spring broke. The ship was
en route to the port of Ghent and was accompanied by
a pilot. The two crew members were both on the ship’s
forecastle. A boatswain suffered an arm injury, and was
able to remain on board. A deckhand suffered serious
head injuries and was taken to hospital in Ghent, for
treatment.
The Maltese Marine Safety Investigation Unit (MSIU) has
launched an investigation.
Classification: Serious injury
Damage following collision with lock
gate, Kiel Canal, Germany, 17 May 2020
While entering the Brunsbuttel lock in the Kiel Canal in
Germany, a Dutch cargo vessel experienced engine failure
on 17 May 2020. As a consequence, the vessel collided
with the lock gates, causing serious damage both to the
vessel and the lock gates.
The German Bundesstelle für Seeunfalluntersuchung (BSU)
has launched an investigation.
Classification: Less serious
Grounding following engine failure,
Vlieland, 12 October 2020
Vlieland following engine failure. The vessel had set
sail from Harlingen, during the night. At around 4 a.m.,
the boat experienced problems with its reversing gear
coupling. The boat became unmanoeuvrable, and was
forced by wind and current out of the navigation channel
and onto the beach, where the ship remained high and
dry, upright, without any risk to the persons on board.
That morning, a salvager attempted to pull the ship clear,
but there was insufficient water depth. In the afternoon,
the vessel was pulled clear, and sailed to Harlingen under
its own power.
The Belgian Federal Bureau for the Investigation
of Maritime Accidents (FEBIMA) has launched an
investigation.
Classification: Serious
Containers lost, Pentland Firth,
United Kingdom, 31 October 2020
On the afternoon of Saturday 31 October 2020, a Dutch
cargo vessel lost 33 containers after entering the North
Sea via the Pentland Firth, north of Scotland. The vessel
was travelling from Straumsvik (Iceland) to Rotterdam. Of
the 33 containers, 1 contained consumer goods, and the
rest were empty. Wind was blowing at force 8 with gusts
up to force 9. The vessel was sailing almost directly into
the wind and waves.
The captain had seen the weather forecasts. The forecasts
suggested that weather on the North Sea would be more
favourable than in the Atlantic. However, the opposite
was the case. When the vessel entered the North Sea, it
experienced waves of between 4 and 5 metres in height.
The vessel started to react more violently and at one point
a large wave crashed into the ship, and the containers fell
overboard. The duty officer saw it happen.
The Marine Accident Investigation Branch (MAIB) of the
United Kingdom has launched an investigation, with the
Netherlands as a Substantially Interested State. The Dutch
Safety Board is involved in the investigation and when the
vessel arrived in Rotterdam, carried out an investigation
on board, and shared the information with the MAIB.
The English Marine Accident Investigation Branch (MAIB)
has launched an investigation, but this has not yet been
completed
Classification: Serious
Shipping Occurrences Report - 13
 Incidents that have
The Scheldebank was instructed to moor at Fisherhutte, The pilot had come aboard at sea at around 17.00 hours,
where the crew made an initial inspection of the damage. and piloted the vessel into the Caland Canal. The captain
Here they received notice that although the ferry had took over control on reaching the 7e Petroleumhaven. The

not been extensively

suffered serious damage, the passengers on board ship made a turn to starboard before making a parallel
suffered no injuries. The damage to the Scheldebank was reverse landfall. After building up speed, the captain
limited to a few scratches on the ship’s starboard side. decided to transfer control of the ship from the central

investigated
The ship was travelling to Inkoo in Finland, and following
further inspection at the yard in Kiel was permitted to
continue its journey. Another ferry was deployed to
maintain the ferry link.
Classification: Serious
console on the bridge to the console on the port bridge
wing. At this point, the pilot pointed out the post behind
the ship, to the captain, and recommended that the
captain move the ship forward. The captain attempted
to comply with this recommendation, but the adjustable
propeller failed to respond to the controls, as a result of
which instead of slowing down, the ship collided with the
post. After switching back to the central console, and
from there once again back to the port bridge wing, the
operation of the propeller was once again possible.

Collision with dockside, Moerdijk, Classification: Serious

23 May 2020

Upon entering the Northern harbour basin in Moerdijk,

Collisions
Collision between coaster and river ferry,
Kiel Canal, Germany, 8 May 2020
Following a collision between the Dutch coaster
Scheldebank and the Hochdonn ferry on the Kiel Canal,
on Friday 8 May, the ferry suffered serious damage.
The accident occurred shortly before 8.00 hours in the
morning, in poor visibility of between 50 and 100 metres.
Shortly before the railway bridge, the Scheldebank had
reduced speed in connection with diving work from a
barge, in the canal. Shortly afterwards, the crew on the
bridge (pilot, captain and first officer) saw a vague object
on the port side. About two seconds later, the collision
took place between the Hochdonn ferry, which was
formally required to give way, and the Scheldebank. The
stern part of the ferry was hit and suffered severe damage.
on 23 May 2020, the cargo vessel Kalkvik sailing under
the flag of the Faroe Islands collided with the dockside.
There was a pilot on board, but the captain was in control
of the ship. An unexpectedly strong current drove the ship
against the dockside. The dockside suffered damage, as
did the ship, to the ship’s skin. There was no spillage.
Classification: Serious
Collision with mooring post,
7e Petroleumhaven, Rotterdam, Damage to the stern part of the Gisela Essberger. (Source: Rotterdam
6 September 2020 Harbour Police)
While mooring at the Vopak jetty in the Caland Canal
near the 7e Petroleumhaven at Rotterdam’s Europoort,
the Portuguese chemical tanker Gisela Essberger collided
with a mooring post on 6 September 2020. As a result
of the collision, the vessel was punctured about two
metres above the waterline, at the location of a drinking
water tank. A hole with a diameter of 30 centimetres was
punched in the ship

14 - Dutch Safety Board

Occupational accidents Fall from tweendeck, Beaumont Texas, Injury to upper right leg caused by slip
United States, 18 August 2020 with grinder, Harlingen, 26 May 2020

Movable tweendecks The first officer on board the Dutch cargo vessel The seagoing yacht Seawolf was moored by the dock in
Poolgracht was badly injured on 18 August 2020. The Harlingen on 26 May 2020, for maintenance work. While
Crew members on a ship are faced with different first officer was walking on a movable tweendeck in the cutting metal, a hand grinder slipped, hitting a British crew
heights that are regularly subject to change. Crew hold, to check the cargo, and to instruct the fire watch in member. The grinding disc came into contact with his leg.
members must always think carefully about where connection with hot work that was to be carried out. This The crew member spent 1 night in hospital, before being
they can and cannot walk, and the height of the tweendeck had been placed on the first level in the hold. flown home.
floor beneath them. This situation represents a In the process, he tripped or missed his footing, and fell
potential for fatal accidents. This was the case in from the tweendeck. He was able to grasp a handhold and
the fatal accident on the Fortunagracht, whereby a so avoided falling all the way. He was then able to climb
deckhand walked through a door opening behind Classification: Serious injury
back onto the tweendeck. Because of severe pain, he was
which the floor was no longer present. taken to hospital, where he underwent an operation and
was repatriated.
In this Shipping Occurrences Report, one
occurrence is listed involving the injury of the
first officer of the Dutch cargo vessel Poolgracht, Classification: Serious injury
because he fell from a tweendeck (see below). This
occurrence demonstrates clear similarities with the
occurrence on the Fortunagracht about which a
report was published in 2020 (see page 7): Leg injury during work, Delfzijl,
16 May 2020
Fall from height, fatal accident on
board Fortunagracht, Puerto de On 16 May 2020, the Dutch cargo vessel Alecto was
Sucre, Venezuela, 16 February 20187. moored in the port of Delfzijl. Maintenance work was being
carried out in the hold. The first officer suffered serious leg
injuries. The injuries required treatment on shore, so the
victim was taken to hospital.

Classification: Serious injury

7 ht t p s: //w w w.o n d er zo e k s r aa d.nl /nl /p ag e /1716 6/v al -v a n - ho o g te - - -

dodelijk-ongeval-aan-boord-fortunagracht

Shipping Occurrences Report - 15

 Broken leg, on the Elbe, Germany,
Incidents that have 28 May 2020
not been extensively An accident took place on board the Dutch workboat
investigated Torsten, on 28 May 2020, resulting in a deckhand breaking
his lower leg. The accident took place while bringing on
board a buoy that was used to mark the anchor line. The
anchor line is used to hold a floating pipeline in position
(for sand suppletion) when not connected to a dredging
vessel. The accident happened after the buoy had been
brought on board, in preparation for disconnecting the
pipeline from the anchor, and connecting it to a dredger.
After the deckhand signalled that the buoy should be
lifted, the winch operator started to lift the buoy. Shortly
after the buoy had been brought on board and placed on
deck, the sudden tension on the anchor line caused the
winch cable and buoy to shift to starboard. The deckhand
was standing midships on the starboard side, guiding the
winch cable with a short boat hook. The winch cable came
into contact with the victim’s lower right leg, throwing him
to starboard; it eventually turned out his leg was broken.
The German water police came on board following the
accident.
Classification: Serious injury
16 - Dutch Safety Board
Fingers trapped in fishing net, North Sea
above Terschelling, 3 June 2020
On 3 June 2020, an occupational accident took place on
board the Dutch fishing boat ZK10 Vijko Sr. The boat was
fishing on the North Sea above Terschelling, when a crew
member’s hand became entangled in the fishing nets.
As a result, the deckhand lost two fingertips. The injured
crew member was disembarked by a KNRM lifeboat, and
subsequently treated in hospital.
Classification: Serious injury
Broken arm during work on deck,
German Bight, 11 June 2020
While securing material on deck of the UK149 Stella Maris,
in preparation for a homeward journey from the German
Bight, the upper arm of a crew member became trapped
following an unexpected movement by the vessel. The
crew member’s upper arm was broken in the accident,
and he had to be disembarked by medical evacuation and
transported to a Danish hospital.
Classification: Serious injury
Broken leg, Scotland, United Kingdom,
15 June 2020
On board the Dutch stern trawler SCH123 Zeeland, sailing
at sea off the coast of Scotland, on 15 June 2020, while
changing the otter boards, one otter board collided with
the leg of the boatswain, breaking his leg. The victim
was evacuated by helicopter, and transported to hospital
near Inverness. From there, the victim was eventually
transported to the Netherlands, where he underwent an
operation.
Classification: Serious injury
Lost finger phalanx, English Channel,
United Kingdom, 24 June 2020
In the afternoon of 24 June 2020, a crew member of the
tugboat Teddy trapped his finger, and as a result lost the
tip of this right index finger. The victim was carrying out
towing work on deck, which required him to connect the
towing cable to the connector. During this process, the
stretcher of the towing line slipped, trapping the victim’s
hand between the stretcher and the plate. The victim
underwent treatment in hospital.
Classification: Serious injury
Foot broken by entrapment, Rotterdam,
02 July 2020
On 2 July 2020, on board the Dinteldijk, moored in the
port of Rotterdam a crew member’s foot became trapped
between the bulkhead and the ship while relocating a
bulkhead. The bulkhead shifted suddenly while the crew
member was attempting to disconnect it. He was taken to
hospital, where a bone fracture was diagnosed.
Classification: Serious injury
Classification: Serious injury
Leg between fishing cables,
Shetland Islands, United Kingdom,
7 July 2020
In the afternoon of 7 July 2020, a deckhand on the
fishing vessel SCH302 Willem van der Zwan trapped his
leg between the fishing cables he was guiding. While
hauling in the cables around the drums, the cables
became entangled behind the victim, causing his leg
to be trapped. As a result, he was pulled up against the
guide frame, leading to a broken ankle and fibula. The
victim required hospital treatment, and was evacuated by
helicopter.
In response to the occurrence, the operating position for
the drums was examined. Before the accident, the only
available drum operating position was on the starboard
side. To ensure a clearer overview of the activity, a control
panel will also be mounted on the port side. Depending
on the situation, the drums can then be operated either
from the port or starboard side.
Reconstruction photograph of the accident. On the left, the position
of the victim. (Source: Van der Zwan)
Classification: Serious injury
Shipping Occurrences Report - 17
 Crew member suffers serious injuries
Incidents that have during mooring, Rocky Point, Jamaica,
not been extensively 19 July 2020
investigated On 19 July 2020, a deckhand on board the Dutch cargo
vessel Hanze Goteborg was hit in the chest by a mooring
line while mooring in Rocky Point Jamaica. While
approaching the dockside, the mooring line in question
was paid out. At a certain point, the line became caught
around the drum. The deckhand attempted to release the
line, but because the ship was still moving, the line came
under increasing tension. When the mooring line eventually
broke free, it hit the deckhand in the chest. The deckhand
suffered serious injuries. The victim was hospitalized in
Jamaica, for observation. The ship subsequently left for
Rotterdam, leaving the deckhand behind.
Fatigue may have been a contributing factor in the
accident; due to COVID restrictions, it was not possible
to change the crew members after completing the normal
contract period; he had been on board since 31 May 2019.
Classification: Serious injury
18 - Dutch Safety Board
Crew member breaks finger, anchorage
Scheveningen, 20 July 2020
A crew member on board the Dutch passenger ship the
Nieuw Statendam was carrying out an inspection of the
sprinklers midships on deck A on 20 July 2020. While
attempting to stop a fire-retardant door from closing, his
finger became trapped between the door and the hinge.
He suffered an open fracture to his right middle finger.
The crew member received treatment for his injury from
the ship’s medical team in the hospital on board the
passenger ship. At that time, the Nieuw Statendam had
been anchored in the North Sea, off Scheveningen, for
several months, as a result of the forced shutdown of cruise
operations due to the COVID-19 outbreak. In connection
with COVID-19 restrictions, the crew member in question
had been on board since December 2019.
Classification: Serious injury
Lost fingertip, Lerwick, United Kingdom,
9 August 2020
On 9 August 2020, a crew member on board the Dutch
stern trawler SCH81 Carolien lost a fingertip. The accident
took place when the crew member attempted to remove
a hook from one of the otter boards, while hauling in the
fishing gear. The hook had become stuck in the otter
board while shooting the gear. After contact with the
Radio Medical Service, the crew member was transported
to hospital, before being repatriated.
Classification: Serious injury
Broken ankle, Ipswich, United Kingdom, Cut knee from badly placed angle Facial injury, Western Coast of Taiwan,
10 August 2020 grinder, North Pacific, 21 August 2020 21 August 2020

On 10 August 2020, the Dutch cargo vessel Reggedijk was On 21 August 2020, the Dutch cargo vessel On 21 August 2020, a medical evacuation was carried out
moored in the port of Ipswich. While moving supplies that Merwedegracht was sailing off Mexico, in the northern from the Dutch ship Seahorse, when the ship was sailing
had just been brought on board, the ship’s cook slipped Pacific. A deckhand was working in the hold with an angle close to Taiwan’s western coast. A crew member suffered
while moving a box of fresh vegetables. He broke his grinder. While setting the angle grinder to one side, it facial injuries due to accident and was transported to
ankle. After visiting the local hospital, he was repatriated came into contact with his knee. Although the machine hospital by the Taiwanese coastguard.
for an operation. was switched off automatically when it was released, the
disc was still rotating fast enough to cause a serious cut in The accident took place while he was raising a beacon
the deckhand’s knee. On the advice of a doctor from the for measuring instruments on board, for measuring
Radio Medical Service, the wound was stitched on board. instruments. The cable on the hauling winch he was using
Classification: Serious injury
The victim was able to remain on board, and after about became trapped around the railing. As he attempted to
one week was able to fully return to work on board. disconnect the beacon, he was hit in the face by the cable.
He received first aid on board, and on the advice of the
Dutch Radio Medical Service doctor was then transported
Classification: Serious injury
Facial injury from broken mooring line, to hospital, where he underwent an operation.
anchorage Konta, Guinea,
15 August 2020
Classification: Serious injury
On 15 August 2020, a crew member of the Dutch cargo
vessel Alecto lost a number of teeth and suffered injuries
to his face, tongue and palate. The accident took place
during a manoeuvre whereby the vessel was mooring
against a crane ship. The two ships separated during the
manoeuvre because of the 1.5 to 2 metre-high swell. As a
result, the mooring line which had already been paid out
suddenly came under severe tension. The mooring line
hit the crew member in the face, causing the loss of some
teeth. The victim was disembarked and taken to hospital.
Following treatment, he was able to recover further, at
home.

Classification: Serious injury

Shipping Occurrences Report - 19


Incidents that have Hatch cranes
not been extensively Incidents involving hatch cranes occur regularly.
On 5 September 2020, a further accident took
investigated place. The second mate of the Zaanborg was
injured, when he became trapped between the
hatch cranes and the railing (see below). Working
with hatch cranes was previously the subject of
two reports from the Dutch Safety Board, in which
both cases led to a fatal outcome. These are the
accidents on the Lady Christina (published on
9 May 2018 8) and on the Beauforce (published on
19 April 2016 9 and the second fatal accident in 2018
is now under investigation).
A hatch crane travels over holds or stacked hatches,
such that the operator of the hatch crane has no
clear view of everything taking place around the
hatch crane. Because these are regularly recurring
accidents, the Dutch Safety Board once again draws
attention to safe working with hatch cranes. In the
investigations involving the Lady Christina and
Beauforce, recommendations were made about
working with hatch cranes, and whenever working
with hatch cranes, it is recommended to know the
investigations.
8 https://www.onderzoeksraad.nl/en/page/4879/aanrijding-door-kraan-aan-
boord-lady-christina-15-november-2017
9 https://www.onderzoeksraad.nl/en/page/3990/beknelling-luikenwagen-9-
juni-2015
20 - Dutch Safety Board
Trapped by hatch crane, St. Petersburg,
Russia, 5 September 2020
On 5 September, 2020, the second mate on board the
Dutch cargo vessel Zaanborg was injured, while the ship
was moored in the port of St. Petersburg, Russia. Also in
this case, the second mate became trapped between the
moving hatch crane and the railing of the ship.
At the location of the front hatch, the gangway (waist) dips
lower than elsewhere on board. For this reason, above
this section of gangway, a platform has been created from
which the hatch combing can be reached. For example
for cleaning the hatch combing and for clearing the hatch
crane runway. The platform can only be reached if the
hatches are closed, or by climbing along the railing.
The second mate was on this platform, without the hatch
crane operator knowing, when the hatch crane was also
being used to retrieve the next hatch from the stack, to
place it further back over the hold. The crew present on
board had assumed that the second mate was in the waist
and not on the platform. In hindsight, the second mate was
positioned almost immediately below the crane operator,
but out of his field of vision. In the previous minutes, he had
allowed the hatch crane to pass the gangway on several
occasions, at different locations, although there is very
little space between the hatches and the railing, over the
length of the ship. Both the duty officer and the operator
on the hatch crane were in possession of a walkie-talkie.
While the crane operator was focused on picking up the
hatch, the overall of the second mate apparently became
caught on part of the hatch crane. The second mate called
out ‘hold’ which was heard by the crane operator. He
thought the cry related to the fact that the hooks on the
hatch had not been correctly hitched, which was indeed
the case at that time. Following a correction, he assumed
that he was free to continue. However, the second mate
had not yet succeeded in freeing himself, and from that
position was unable to reach the emergency stop. As the
crane started moving, the second mate became trapped.
He screamed in pain, at which point the crane was halted
immediately, and assistance was provided, without delay.
Classification: Serious injury
Fall from height with man basket,
St. Petersburg, Russia, 15 September 2020
On 15 September 2020, the boatswain of the Eemsborg
fell into the hold, from a considerable height. Bulkheads
had previously been installed, in preparation for loading
in St. Petersburg. To repair a section of the seal that had
broken free, use was made of a man basket suspended
from the store crane of the hatch crane. While carrying
out this work, the man basket containing the boatswain
was dropped from a height of 9 metres. According to the
procedures on board, the man basket should have been
secured with a fall arrester, but this was not carried out in
this instance. The man basket slipped out of the hook on
the store crane. The pin for the hook probably failed to
close, leaving the hook open. It is uncertain how the man
basket slipped out the hook. The boatswain was taken to
hospital in St. Petersburg, with serious injuries.
Classification: Serious injury
Shipping Occurrences Report - 21
 Injury to thumb, west of Scotland, Thumb in door, Ionian Sea,
Incidents that have United Kingdom, 25 September 2020 3 October 2020
not been extensively In the early morning of 26 September 2020, a crew On 3 October, while closing a watertight door on the
investigated member of the Dutch cargo vessel Stadiongracht was
evacuated by helicopter, after seriously injuring his thumb.
Dutch cargo vessel Bothnia, a crew member’s thumb was
trapped in the door. After First Aid on board and contact
with the Radio Medical Service, a helicopter was deployed
On the previous day, the crew member had been working for a medevac. At the time, the ship was sailing on the
in the engine room replacing the exhaust valve in a Ionian Sea.
cylinder head. The crew member needed both hands to
replace the exhaust valve, and had to crouch to see what
he was doing. At precisely that moment, the ship made
Classification: Serious injury
a rolling motion, causing the crew member to lose his
balance. He dropped the exhaust valve, which fell onto his
thumb.

Trapped between mooring lines, Via the Dutch Coastguard, the captain contacted the
Vlissingen, 15 September 2020 Radio Medical Service. After speaking to the duty doctor,
the information was passed on to MRCC Stornoway. The
decision was eventually taken to evacuate the victim.
During the mooring process in the Kaloothaven in Because the ship was sailing around 600Nm west of
Vlissingen on 15 September 2020, a crew member of Scotland at the time, MRCC Stornoway deployed a
the Maltese cargo vessel Wilson Borg became trapped helicopter to retrieve the victim.
between mooring lines that were pulled taut. He suffered
an open fracture to the leg. At the moment of the accident,
the springs and bow lines had already been paid out, and
Classification: Serious injury
the stern lines were being taken ashore by the boatmen
on their flatboat. For unknown reasons, the victim on
the forecastle became entangled in the bow lines. The
victim was disembarked by the fire brigade, and taken to
hospital.

Classification: Serious injury

22 - Dutch Safety Board


Working without experience
Last year, it once again became clear that obtaining
a certificate on the basis of the provisions in the
International Convention on Standards of Training,
Certification and Watchkeeping for Seafarers (STCW)
is not enough to ensure safe working practice on
board, because practical experience is an equally
essential element. This applies for example to
inexperienced crew members such as the trainee
who fell three metres, and broke both his arms. The
captain had issued instructions on use of the mobile
ladder, but these instructions were not correctly
followed (see below). On board a ship there are
constantly potential hazards and knowledge and
experience determine how those hazards are dealt
with, and how the situation ends up. If someone has
never done something before, and sees someone
else carrying out a task that appears simple, the idea
can soon take root that the task is indeed simple.
This in turn can lead to overconfidence in a person’s
ability; that person may assume he has certain skills,
which he does not in fact have, at all. Next to that,
a trainee receives, on any given day, a great deal
of new information, and cannot be expected to
immediately correctly process and comply with all
that information.
10 https://www.onderzoeksraad.nl/en/
In the Shipping Occurrences Report of November
2017 - April 201810, attention was focused on this
subject. It was suggested in that edition of the SOR
that consideration must also be given on board to
who is capable of determining each individual’s
learning needs and ensuring that trainees are able to
make mistakes in a safe environment, and that those
mistakes are discussed. People should not be set to
work independently too quickly, for their own safety.
When discussing this subject, thoughts quickly turn
to deckhands who have just completed training,
but it can apply to any position on board, when a
crew member is given new tasks and responsibilities.
Take for example a maritime officer who had just left
school, and who was immediately made responsible
for the engine room. As a consequence, he took
certain actions, due to his lack of experience, which
went wrong, and caused a fire This investigation is
dealt with in the chapter Accidents investigated
without report (see page 10) and is titled:
Fire in engine room, Maas
approaches, 26 June 2017
Trainee falls from ladder and breaks both
arms, Mukran, Germany,
13 October 2020
On 13 October 2020, the Dutch cargo vessel Hestia was
moored in the German port of Mukran. After unloading
a cargo of steel pipes, the crew was instructed to clean
the hold and prepare it for the next cargo. The crew
included a trainee. He was working under the captain’s
supervision. The trainee was working with a mobile ladder.
Shortly before starting the work, he was instructed by
the captain on the use of this ladder. The way the trainee
eventually placed the ladder was not in compliance with
the instructions. The captain saw this happen, and despite
a shouted warning by the captain, the trainee and ladder
fell approximately 3 metres. The trainee broke both arms,
and had to be taken to hospital.
Classification: Serious injury
Shipping Occurrences Report - 23
 Ship’s cook suffers burns, Bay of Biscay,
Incidents that have 28 October 2020
not been extensively
On 28 October 2020, the ship’s cook on board the Dutch
investigated cargo vessel Arklow Breeze suffered serious burns to his
hand. While frying fish, the cook knocked into the frying
pan, causing it to tip over and thereby spilling hot oil on
the cook’s hand. The movements of the ship due to severe
weather were a contributing factor. Following arrival in the
port of Bordeaux, the cook was taken to hospital to have
the burns treated.
Classification: Serious injury
24 - Dutch Safety Board
Fire on board
Fire due to heat generation in cargo of
scrap metal, Waalhaven, Rotterdam,
04 July 2020
Fire broke out on board the bulk carrier Dimitri S sailing
under Liberian flag, while in the Waalhaven. The fire was
caused by heat generation in the cargo of scrap metal that
had previously been taken on board in Dordrecht. One crew
member was taken to hospital with breathing problems,
having inhaled smoke. A number of crew members were
temporarily disembarked and accommodated elsewhere.
The other crew members remained on board to assist the
fire brigade. Putting out this complex fire took 12 hours
during which time large volumes of smoke were generated,
which caused considerable nuisance in the environment.
Several NL-alert messages were transmitted in response.
Classification: Serious
Chimney fire, Killingholme,
United Kingdom, 04-07-2020
On the evening of Saturday 4 July 2020, a chimney
fire broke out on board the Stena Transit. This fire was
caused by an overflow from the day tank for fuel. The fire
was rapidly brought under control, and the damage was
limited to electrical parts. As a consequence, the scrubber
(exhaust gas filter) and second generator were put out of
action. The classification society completed an inspection
on board, after which the vessel was returned to service.
Classification: Serious
Fire in engine room, Vlissingen,
6 July 2020
On 6 July 2020, fire broke out in the engine room of the
Danish-flagged Wilson Arctic. Shortly before, the offshore
supply boat had set sail from the Sloehaven in Vlissingen.
The vessel was travelling without cargo, with 49 people on
board, in the vicinity of the Steenbank pilot station. The
fire was soon brought under control. There were no injuries
and no environmental pollution. One of the main engines
was still operable, and the pilot, who was still on board
at the time, informed the authorities that the propulsion
generated by a single engine was sufficient for the vessel
to continue sailing. The vessel returned to the Sloehaven,
under its own power.
Classification: Serious
Fire during welding work, Kiel, Germany,
20 September 2020
On 20 September 2020, fire broke out in the engine room
of the Dutch sailing ship Regina Maris. Two persons on
board suffered injuries. At the moment of the accident, the
ship was moored in the port of Kiel, and there were no
passengers on board.
Together with a welder, the captain was carrying out
maintenance work in the engine room. After cleaning the
reversing gear coupling with brake cleaner, the welder
moved to the other side of the engine room to start
welding the engine bracket. As he started welding there
was an explosive combustion and fire broke out.
The captain first attempted to extinguish the fire himself,
but was forced to abandon his efforts due to lack of oxygen.
The fire was later put out by another crew member. The
welder evacuated the engine room immediately following
the explosion. He suffered burns to his arms and was
taken to hospital in Lübeck by emergency helicopter. The
captain was admitted to Kiel hospital, where he remained
overnight for observation, with minor injuries.
Due to the absence of other flammable materials in the
engine room and the risk of flammable gases in enclosed
spaces, the likely cause is that the propellant gases from
the brake cleaner had become trapped in the bilge, and
were ignited by the welding sparks.
Classification: Serious injury
Shipping Occurrences Report - 25
 Grounding following blackout,
Incidents that have Nieuwe Maas, 25 May 2020
A salvage company was eventually called in, which arrived
on the morning of Sunday 26 July, with a salvage vessel

not been extensively

On 25 May 2020, the Cypriot container ship Elbfeeder
investigated ran aground on the northern bank of the Nieuwe Maas
just above the Koggehaven, as a result of a blackout. This
and a tug. After a channel was dug by a contracted Danish
dredger, the UK172 was successfully refloated on the
evening of Monday 27 July, more than a week after the
initial grounding.

was caused by the failure of the main engine due to a
problem in the alarm system. The crew attempted to avoid
running aground by dropping anchor, but without success.
The ship was refloated with the assistance of a tugboat,
and assisted by two tugs continued its journey to the
Eemhaven. There were no leaks or spills.
The UK172 was towed to Thyboron in Denmark to unload
its fish and to inspect the boat. The boat was then towed
to IJmuiden for repairs. The vessel suffered damage to its
keel and superstructure as a result of the grounding and
recovery. The engine will also have to be overhauled/
replaced.

Classification: Serious Classification: Serious

Groundings

Grounding due to fishing net in Stranded on the Danish Coast, Denmark,

propellor, Scheveningen Coast,
14 May 2020
On 14 May 2020, while fishing on the North Sea off the
coast of Scheveningen, a fishing net became entangled
in the propeller of the Dutch trawler WR181 Gerritje. As
a result, the trawler lost control of its steering. Towing
assistance was initially provided by the Dutch trawler SL2
Arentje. In the approach to the port of Scheveningen,
assistance was requested from the Dutch lifeboat service
KNRM, via the Coastguard Centre. A KNRM lifeboat took
over the towing and towed the trawler into the port of
Scheveningen.
Classification: Serious
20 July 2020
On Monday 20 July 2020, the Dutch fishing boat UK172
Sursum Corda suffered engine failure while fishing
off the Danish coast. An initial inspection revealed a
seized-up cylinder in the main engine. In addition, there
was no more lubricating oil in the engine block. This was
clearly a problem that could not be repaired at sea, and
it immediately became clear that tugboat assistance was
required.
In the meantime, the boat had been driven closer towards
the Danish coast, and after the nets were hauled on board,
the drift accelerated. The anchor was deployed, but failed
to take hold, and started dragging. By this time, towing
assistance in the form of fellow fishing boats was en route,
but they did not arrive on time to prevent the UK172
running aground.

Over the course of the days following the grounding,

several attempts were made to refloat the fishing boat,
involving a number of other fishing boats from Urk.
All these attempts failed, partly as a result of the poor
weather. As a consequence, the UK172 became more
deeply embedded on the shore.

26 - Dutch Safety Board

Stranding due to failure of steering gear,
Westerschelde, 7 September 2020
At 20.25 hours on 7 September 2020, an electrical wire in
the steering gear on board the bulk carrier Antero, sailing
under the flag of the Marshall Islands, broke, causing the
steering gear to fail. As a result, the vessel made a turn to
starboard. Despite immediately activating the emergency
steering system, the vessel crossed the northern line
of buoys, and ran aground on the Westerschelde, near
Terneuzen.
As the water level was falling, the vessel could no longer
be dragged clear and other shipping traffic was informed
by the traffic control centre in Terneuzen to pass with
caution. At around 01.45 hours, with the incoming tide, the
ship rose clear and was towed to the roads of Vlissingen
by tugboat, to wait for a mooring in the port. The steering
gear was repaired in Vlissingen, and the vessel was
inspected for damage, before continuing on its journey.
Classification: Serious
Grounding outside the buoy line,
Limfjord Denmark, 6 October 2020
On 6 October 2020, the Dutch cargo vessel Daan was
travelling from Aalborg towards Logstor, under pilot
guidance. The pilot had instructed the vessel to continue
sailing tight along the red side of the channel, to allow
another ship to overtake. At this point, the navigation
channel is narrow, and the green and red channel markings
appear to line up with one another, due to the bend. The
Daan passed a green marker buoy on the eastern side,
outside the channel, and subsequently ran aground. The
Daan was successfully refloated with the assistance of a
nearby pilot boat and was able to continue its journey.
An inspection revealed that the vessel had suffered no
damage as result of the grounding.
Classification: Serious
Grounding following incorrect
assessment of a buoy, Randers Fjord,
Denmark, 24 October 2020
On 24 October 2020, the Dutch cargo vessel Eems Sky
ran aground in the Randers Fjord in Denmark. When it ran
aground, the vessel was sailing without pilot assistance.
The cause of the grounding was the wrong assessment of
a buoy by the bridge team. On Monday 26 October, the
ship was refloated and continued its journey to Randers.
An underwater inspection was carried out, revealing no
damage.
Classification: Serious
Shipping Occurrences Report - 27

Incidents that have Damage
not been extensively Broken hawser damages lifeboat,
Vlaardingen, 26 August 2020
investigated
On 26 August, at around 07.40 hours, the Lithuanian RoRo
cargo vessel Gardenia Seaways was attempting to enter
the Vulkaanhaven in Vlaardingen. Due to poor weather,
the vessel was assisted by two tugs. One of the hawsers
broke, causing severe damage to the lifeboat of the
Gardenia Seaways. The vessel subsequently entered the
port, without further problems.
Classification: Serious
28 - Dutch Safety Board
Fishing net in propeller,
north of Vlieland, 17 September 2020
On 17 September 2020, while fishing, a fishing net became
entangled in the propellor of the Dutch fishing boat WL39
Monte Senior causing the fishing boat to lose all power.
The net in question was not the boat’s own fishing net,
but a net that was floating in the sea. The fishing vessel
was towed to Lauwersoog by a fellow fishing boat, where
it was placed on the slipway, to remove the net. No further
damage to the fishing boat was observed.
Classification: Serious
Broken free from dockside, Zeebrugge,
Belgium, 25 September 2020
In the early morning of 25 September 2020, the Dutch
gas tanker Coral Monactis broke free from the dockside
in Zeebrugge. At the time, a storm was traversing
western Belgium and the southwestern Netherlands.
After breaking free, the vessel was pushed back to the
dockside by a tugboat, so that new mooring lines could
be laid. The ship suffered damage to its portside, but was
not punctured. Following inspection, the vessel visited a
shipyard for repairs.
Classification: Serious
Damage to mast due to collision with
container crane, Rotterdam,
4 October 2020
At 06.30 hours on 4 October 2020, the Liberian container
ship Nordic Luebeck hit a container crane with its main
mast during a mooring manoeuvre at the ECT terminal. As
a result, the mast was knocked completely out of alignment
and had to be repaired before the ship could continue its
journey. The ship was sailing under pilot supervision and
was instructed to moor at the designated location on the
dockside, beneath the crane. During the manoeuvre, it
became clear that there was insufficient space beneath the
crane for the height of the ship, but there was no more
time to break off the manoeuvre. The crane beneath which
the ship was moored was mistaken for a different, higher
crane.
Classification: Serious
Collision with post, Eemshaven,
5 October 2020
In the early morning of 5 October 2020, at around 02.45
hours, the Dutch fishing boat Noorderhaaks UK 195
collided with a post when leaving the Beatrixhaven in
Eemshaven. The collision was caused by a loss of steering
when a large ship passed by.
According to the skipper, the fishing boat suffered a tear,
2 metres above the waterline. The boat will remain moored
until an inspection has been carried out to identify the
damage so the emergency repairs can be carried out.
Classification: Serious
Shipping Occurrences Report - 29

Incidents that have
not been extensively
investigated
Damage while manoeuvring, IJmuiden,
28 October 2020
The 110 m-long Portuguese cargo vessel Manisa Floyen
was damaged while manoeuvring in the port of IJmuiden,
on 28 October 2020. While moving to a different berth,
the vessel was caught by a gust of wind, which forced
the vessel against the corner of a platform, puncturing a
hole in the hull, above the waterline. The ship was able
to continue mooring without further difficulty, and the
crew carried out provisional repairs before continuing
the journey. Because the class regulations specify an
inspection and repair, the vessel was recalled to port.
Classification: Serious
30 - Dutch Safety Board
Technical failures
Ship loses steering and requires tugboat
assistance, North Sea in the vicinity of
Vlieland, 5 June 2020
On 5 June 2020, during a journey from Tilbury in the
United Kingdom to Klaipeda in Lithuania, the cargo vessel
Geise suffered a complete blackout at around 13.30 hours,
while on the North Sea, in the vicinity of Vlieland. The
vessel was towed to the port of Rotterdam, by tugboat.
Classification: Serious
Towed into port following engine failure,
North Sea, 23 June 2020
In the night of 22 to 23 June 2020, the fishing boat Anna
Tatjana WR222 experienced problems at sea with the
cooling water system in its main engine. As a result, the
fishing boat was unable to continue sailing, and had to be
towed into the port of Den Helder.
Classification: Serious
Failure of steering gear, Westerschelde,
7 July 2020
On 7 July 2020, the Dutch sand dredger DC Brugge
suffered a failure of its steering gear. The vessel first
anchored to allow the crew to carry out temporary repairs.
The vessel then entered the port of Breskens under its
own power. Definitive repairs were carried out in Breskens.
Classification: Serious
Problems with the cooling system,
Shoreham, United Kingdom,
24 August 2020
On 24 August 2020, the Dutch cargo vessel Reggedijk
was en route from Shoreham in the United Kingdom to
Portugal. Shortly after leaving the port of Shoreham,
the vessel suffered engine problems. The cooling water
pressure in the engine became unstable due to air in the
cooling system. The Reggedijk set its anchor, but the
repair was beyond the capability of the crew. The vessel
was towed to Le Havre, France, for repairs.
Classification: Serious
Engine failure, Anticoste Island, Canada, Sinking, capsizing, taking on water
27 August 2020
Water leak due to cracked GRP pipe,
On Thursday 27 August, the Dutch cargo vessel Amurborg Atlantic Ocean, 5 October 2020
suffered an engine failure, 18 miles southwest of Anticoste
Island, Canada. It quickly became clear that the problems
could not be solved easily, and the vessel was towed into On 5 October 2020, the Dutch heavy cargo vessel
the port of Sept-Iles in Canada. Yacht Express took on a large quantity of seawater. This
happened when the vessel was sailing on the Atlantic
When the engine was inspected, piston no. 6 was found to Ocean. The cause was failure of part of a Glassfiber
have seized. The probable cause was serious damage to Reinforced Plastic (GRP) pipe in a pump room. The crew
the cylinder lining, by the piston pin. decided to close the watertight doors, and switched on
the bilge pump. The decision was also taken to set course
for the nearest safe haven, Freeport on the Bahamas. En
route to Freeport, it became clear that the capacity of the
Classification: Serious
bilge pump was insufficient. Therefore it was decided to
transport additional pump capacity to the vessel. Thanks
to this additional pump capacity, the pump room was
successfully pumped dry, allowing the crew to close the
shut-off valves.

Classification: Serious

Engine failure, Karlshamn, Sweden,

24 October 2020

On 24 October 2020, the Dutch cargo vessel Lady Astrid

was travelling from Karlshamn in Sweden to Chatham in the
United Kingdom with a cargo of timber, when it suffered
a main engine failure in international waters on the North
Sea, off the coast of Noord-Holland. The main engine was
shut down and investigation revealed that cooling water
has flooded part of the main engine. This situation could
not be corrected at sea. Tug assistance was required, and
the Lady Astrid was towed into IJmuiden.

Classification: Serious

Shipping Occurrences Report - 31

 The Dutch
Safety Board What does the
Dutch Safety Board do?
Living safely, working safely, safety. It
in three seems obvious, but safety cannot be
guaranteed. Despite all knowledge
and technology, serious accidents
questions
happen and disasters sometimes
occur. By carrying out investigations
and drawing lessons from them,
safety can be improved.
In the Netherlands the Dutch Safety
Board investigates incidents, safety
issues and unsafe situations which
develop gradually. The objective of
these investigations is to improve
safety, to learn and to issue recom-
mendations to parties involved.
What is the
Dutch Safety Board?
The Dutch Safety Board is indepen-
dent of the Dutch government and
other parties and decides for itself
which occurences and topics will be
investigated.
The Dutch Safety Board is entitled to
carry out investigations in virtually all
areas. In addition to incidents in
aviation, on the railways, in shipping
and in the (petro-)chemical industry,
the Board also investigates
occurences in the construction sector
and healthcare, for example, as wel
as military incidents involving the
armed forces.
32 - Dutch Safety Board
Who works at the Dutch
Safety Board?
The Board consists of three
permanent board members under
the chairmanship of Jeroen
Dijsselbloem. The board members
are the public face of the Dutch
Safety Board. They have extensivve
DUTCH
knowledge of safety issues. They also SAFETY BOARD
have extensive administrative and
social experience in various roles.
The Safety Board’s bureau has
around 70 staff, two-thirds of whom
are investigators.
Visit the website for more information
www.safetyboard.nl.
Colofon
This is a publication of the Dutch Safety
Board. This report is published in the Dutch
and English languages. If there is a
difference in interpretation between the
Dutch and English versions, the Dutch text
will prevail.
March 2021
Photos
Photos in this edition, not provided with a
source, are owned by the Dutch Safety
Board.
Source photos frontpage:
Photo 1: The Netherlands Coastguard
Photo 3: Crew Nordic Luebeck